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The Compliance Team
Exemplary Provider Satisfaction Measure© — Community Pharmacy Survey
Requested By: Edward Arabov at
Your Name:
First:      Last:
Your Phone #:
New or Existing Patient:   
Service Category:
Model or Serial # (as applicable):
Date Of Service:  (mm/dd/yyyy format)
Pharmacist or Pharmacy Tech Name:

 Access, Delivery and ServiceYesNoN/A
1Responses to questions, concerns were addressed in a timely manner.
2Service friendly, prompt and courteous.
3Satisfied with the time spent with the Pharmacist.
4Did Pharmacist / Staff request info on other medications currently prescribed.
5Satisfied with medication counseling / instructions provided by the Pharmacist.
6Satisfied with the length of time for prescription processing.
7Received info on Patient Rights and Responsibilities.
8Satisfied with the service. Would recommend to others.


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